Case Number : Case 1913 - 28 Sept - Dr Arti Bakshi Posted By: Guest

haven't seen this before, ?ischaemic ulcer secondary to arteriosclerosis

Dear All 

Please do attend the following and let colleagues know:

Liverpool Update in Dermatopathology

Tues 28th November 2017

Organised by DermpathPRO & Supported by the British Society of Dermatopathology

https://dermpathpro.com/liverpool-update-2017/

Agree with Urmilapandey. There is some scleredema-like feature...?Diabetic microangiopathy ?Ulcerated Scleredema Diabeticorum

This is livedoid vasculopathy according to me. Hyalinized thickened vessel walls, fibrin like deposits in lumina. Late stage is atrophie blanche

Made me think of Martorell's ulcer, Hypertension related or diabetes

Agree with Raul, I thought of Martorell's hypertensive ischaemic leg ulcers too especially with the degree of changes of the subcutaneous arteriole. The occlusive superficial dermal vessels are probably secondary phenomenon. 

The ulcer is excruciating painful to patient, usually with many cardiovascular risk factors including hypertension (in almost all).

Agree with Raul :-) 

hypertensive ulcer

Yes this is Martorell's ulcer (or hypertensive ischaemic ulcer).

Typically, this occurs on lower legs of patients with uncontrolled hypertension and is excruciatingly painful. The patient had a duplex arterial and venous scan which was negative.

As noted in this case, the vessel type involved is an arteriole, hence the changes are typically seen in the vessels at the dermo-subcutaneous junction. There is arteriolar hyalinosis with intimal hyperplasia and almost complete narrowing of the lumen.

Here is a link to a rather similar case put by Dr Carr on dermpathpro a while ago. https://dermpathpro.com/spot-diagnosis-1/2015-spot-diagnoses/december-2015/case-1432-18-december-r1497/ . I did not get the diagnosis then, but having seen this case on dermpathpro, was able to make the correct diagnosis in my case.